Provider Demographics
NPI:1699076117
Name:BATES, DUSTIN L (PA)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:L
Last Name:BATES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11408 KINGSTON PIKE STE 400
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-3976
Mailing Address - Country:US
Mailing Address - Phone:865-392-1888
Mailing Address - Fax:865-392-1889
Practice Address - Street 1:11408 KINGSTON PIKE STE 400
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3976
Practice Address - Country:US
Practice Address - Phone:865-392-1888
Practice Address - Fax:865-392-1889
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000003166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I976498OtherMEDICARE PTAN
TNP01878527OtherRRMEDICARE PTAN
TNQ029343Medicaid